VHA Office of Rural Health
Enterprise-Wide Initiative (EWI) - Workforce Training and Education
Acute-Inpatient Medicine-High Reliability, Learning Environment and Workforce Initiative (AIM-HI)
Background
The Veterans Health Administration (VHA) is facing serious workforce challenges. Many clinicians are experiencing exhaustion, burnout, and turnover, which can lead to delays in care. Physicians working in rural VHA settings report higher rates of burnout than those in urban areas, and rural facilities are struggling with staffing shortages because it is hard to recruit and keep staff.
There is an urgent need to support frontline clinical teams in rural settings with proven strategies that improve team culture, work environments, and staff well-being. The Acute-Inpatient Medicine-High Reliability, Learning Environment and Workforce Development Initiative (AIM-HI) Enterprise-Wide Initiative (EWI) began in fiscal year 2024 to address this need. The program is funded by the Department of Veterans Affairs (VA) VHA Office of Rural Health (ORH).
AIM-HI provides frontline managers and physician leaders in rural hospitals with evidence-based tools to change their team cultures. By building supportive learning environments, teams are empowered to try, adapt, and adopt new ideas while using reliable, consistent work practices. AIM-HI is designed to fit into real clinical work and help staff support one another while caring for Veterans.
AIM-HI is different from many other workforce initiatives because it avoids adding complex processes, long online trainings, multiple committees, or large organizational changes that can overwhelm staff. Instead, it offers simple, easy-to-use, and cost-effective tools that frontline managers and clinical leaders can use in daily work. These tools help create supportive learning environments and shift team cultures so the workforce is more stable and Veterans receive high-quality care.
Goals and Objectives
AIM-HI has several main goals and objectives:
- Address the urgent need for rural workforce development so rural facilities can recruit and retain a strong clinical team.
- Put in place key strategies that build learning and high reliability across VHA, so care is more consistent and dependable.
- Engage frontline leaders, such as unit managers and physician leaders, as the main drivers of positive organizational change.
- Bring proven, research-based leadership practices directly into everyday clinical care.
- Improve the delivery of timely, high-quality, and patient-centered care for rural Veterans.
Methodology
The AIM-HI Enterprise-Wide Initiative uses an evidence-based workforce development intervention called The Relational Playbook. This Playbook is adapted specifically for VHA rural hospital medicine teams. It is a five-chapter eBook that includes research-based resources and 50 brief, do-it-yourself activities that clinical teams can use during their regular work.
The Playbook focuses on common challenges and pain points that teams experience when caring for Veterans. It is designed to be practical and easy to fit into busy schedules so teams can improve how they work together while still providing care.
The Playbook chapters include content on:
- How to create a positive culture.
- How to build a strong team.
- How to intentionally lead a team.
- How to create joy at work.
- How to communicate effectively and use high-reliability practices.
AIM-HI also uses three additional evidence-based strategies to help clinical leaders put the Playbook into practice: behavioral nudges (reminders and prompts that encourage helpful behaviors), leadership coaching, and a monthly learning collaborative where leaders can share experiences and learn from one another.
Implementation of the Playbook follows a four-step process:
- Assess the current state. Clinical teams start by assessing the current state of their learning environment using a 13-item online Learning Environment Assessment Tool. The tool is automatically scored and provides guidance on how to read the results, including areas of strength and areas that could be improved. It also links to Playbook chapters related to those results.
- Select areas for improvement. Clinical leaders such as physicians, nurses, social workers, and pharmacists review the results with their teams. Together, they identify areas where the team already works well and should keep or spread those practices. They also select areas for improvement and discuss which Playbook activities to use during existing meetings or trainings.
- Implement and adapt interventions. Over about six months, teams are encouraged to implement multiple Playbook activities, with a goal of using one to four interventions each month based on their assessment results. The AIM-HI team monitors fidelity to the interventions to make sure the critical parts of each activity are delivered as intended. At the same time, teams can adjust how they deliver the activities so they fit local needs and context.
- Evaluate the impact. Clinical leaders create feedback loops to monitor how well the Playbook interventions are being carried out and how they are performing. They reflect on what they are learning, consider the impact on staff and care, acknowledge any conflict or tension, identify emerging problems, and develop solutions. They then adjust the implementation process as needed.
Participants have reported that AIM-HI changes how teams work together. For example, one 2024 participant shared that their site now builds teambuilding into many activities, such as staff meetings, summits, and leadership meetings, and that this shift has had a big impact on their team culture.
Impact on Rural Veteran Health
AIM-HI supports rural Veteran health by strengthening the workforce that cares for them. The program focuses on empowering and enabling a diverse and highly skilled group of clinicians and staff to consistently deliver high-quality services to Veterans and their families. It does this through workforce development strategies that promote teamwork, supportive learning environments, and reliable, consistent work practices.
Research has shown that health care teams with strong psychological safety, structured leadership support, and ongoing learning opportunities are more stable over time. These teams tend to have lower staff turnover, higher job satisfaction, and better patient outcomes. By building these conditions in rural VHA hospitals, AIM-HI helps ensure that Veterans receive care from stable, confident teams who know how to work well together.
Key Takeaways
- Engaged Workforce. A stable and well-supported workforce helps create stronger relationships between Veterans and their care teams. This leads to more consistent care plans and greater trust in the health care system.
- Fostering Learning and High Reliability. By creating a learning-focused and high-reliability environment, AIM-HI helps rural VHA hospitals deliver higher-quality, evidence-based, and Veteran-centered care.
- Enhanced Workforce Stability. High provider turnover is linked to breaks in continuity of care, more medical errors, and worse health outcomes. These challenges especially affect rural Veterans, who already face barriers such as geographic isolation and limited specialty services. AIM-HI works to reduce turnover and strengthen workforce stability.
- Access to Care. AIM-HI directly benefits Veterans by supporting timely access to care, reducing provider turnover, and improving care coordination and patient safety. Stable teams can see Veterans more regularly and follow care plans more closely.
- Sustainable Professional Development Model. AIM-HI has the potential to transform rural VA health care by stabilizing the workforce and creating a long-term model for professional development and culture change. This helps ensure that Veterans receive timely, high-quality, and equitable care across rural settings.
References
- Gilmartin H. M., Hess E., Mueller C., et al. A pilot study to assess the learning environment and use of reliability enhancing work practices in VHA cardiac catheterization laboratories. Learning Health Systems. 2020.
- Gilmartin H. M., Hess E., Mueller C., et al. Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories. Health Services Research. 2022;57(2):385–391.
- Gilmartin H. M., Connelly B., Hess E., et al. Developing a relational playbook for cardiology teams to cultivate supportive learning environments, enhance clinician well-being, and Veteran care. Learning Health Systems. 2024;8(2), e10383.
- Gilmartin H. M., Connelly B., Daus M., et al. Implementation of the Acute Inpatient Medicine-High Reliability, Learning Environment, and Workforce Development Initiative (AIM-HI) in rural Veterans Health Administration hospitals: A mixed methods evaluation protocol. Journal of Hospital Medicine. 2025;20(1), 33–41.
Download the Printable PDF for Healthcare Providers and Researchers.
Contact
- Heather M. Gilmartin, PhD, NP, AIM-HI EWI Lead and Research Health Scientist, Denver/Seattle Center of Innovation – Rocky Mountain Regional VA Medical Center, Denver, CO. Heather.Gilmartin@va.gov
- Funding Acknowledgement: Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, NOMAD #PRFY-00586.
- Suggested Citation: Gilmartin, H. (2025). Acute-Inpatient Medicine-High Reliability, Learning Environment and Workforce Initiative (AIM-HI). Department of Veterans Affairs, Veterans Health Administration. Washington, DC: Office of Rural Health.
Rural Health - Navigation
- Office of Rural Health Home page:
https://www.ruralhealth.va.gov/index.asp - Enterprise-Wide Initiatives (EWI) page:
https://www.ruralhealth.va.gov/Enterprise-Wide-Initiatives-EWI.asp - Veterans Rural Health Resource Centers (VRHRC) page:
https://www.ruralhealth.va.gov/Veterans-Rural-Health-Resource-Center-VRHRC.asp
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